Treatment of Cognitive and Behavioral Symptoms associated with Alzheimer's Disease

Rudolph C. Hatfield, PhD., edited by Kathryn Patricelli, MA

Even though researchers continue to learn about the disease and propose potential treatments for it, there is no cure for Alzheimer's disease at the time of this writing. There are many drugs that are going through clinical trials at different stages in the process of getting them ready for use. However, at the time of this writing there are only five drugs that are approved by the Food and Drug Administration (FDA) for the treatment of Alzheimer's disease. These drugs are designed to treat the cognitive (thinking) problems, particularly the memory issues that are associated with the development of Alzheimer's disease. These medications can also result in treating other issues such as problems with language and judgment as well as emotional problems that may be related to confusion or complications of the disease.

Doctors may use other medications for both the cognitive and behavioral symptoms of Alzheimer's disease that are not specifically designed to treat the disease. This may include medications designed to deal with improving attention, focus, energy levels, and emotional issues. The specific medications used to treat the person depend on the person's issues, behaviors, and needs. There are great differences in the needs of each person who is diagnosed with Alzheimer's disease. There is also quite a bit of variation in how doctors address these differences across people diagnosed with the disease. In addition to medications, people that are caregivers for individuals with Alzheimer's disease may use certain types of behaviorally based treatments (discussed in another section) to help them adjust in their environment or to cope.

FDA Approved Medications for the Treatment of Alzheimer's Disease

Of the five FDA approved medications used to treat Alzheimer's disease, three of them are classified as cholinesterase inhibitors. These medications are believed to work by increasing levels of a neurotransmitter (a chemical messenger used by the neurons or nerve cells in the brain) known as acetylcholine. These medications slow down the breakdown of this chemical messenger in the brain and result in more of acetylcholine being available in the brain. Acetylcholine is believed to be important in a person's ability to learn and remember new information. Early research studies suggested that people diagnosed with Alzheimer's disease may have low levels of this neurotransmitter in their brain and this may affect their ability to learn and remember information. Memory loss is the most common early symptom of Alzheimer's disease and difficulties with learning and memory worsen as the disease develops. The three cholinesterase inhibitors approved by the FDA are:

Donepizil (the most common brand name of this drug is Aricept): This medication is approved to treat people in any stage of Alzheimer's disease (mild, moderate, or severe).

Galantamine (the most common brand name for this drug is Razadyne): This medication is approved to treat people in the mild-to-moderate stages of Alzheimer's disease.

Rivastigmine (the most common brand name for this drug is Exelon): This medication is approved by the FDA for the treatment of mild to moderate Alzheimer's disease.

Because any type of medication changes the functioning of certain processes that happen in the body, all medications will have side effects associated with their use. The common side effects of the above medications include nausea, vomiting, loss of appetite, increased frequency of bowel movements, and in some cases, mild confusion. For many people that take these drugs the side effects will be mild and will disappear over time. In other cases, doctors can often control them by using other medications or treatments.

Another cholinesterase inhibitor previously used to treat Alzheimer's disease was the drug tacrine (brand name Cognex). However, the use of this drug was generally discontinued in the United States in 2013 due to serious side effects associated with its use.

Another drug approved to treat Alzheimer's disease is called a NMDA receptor antagonist. What this term means is that the drug is designed to reduce the amount of the neurotransmitter NMDA in the body. This neurotransmitter speeds up the actions of the neurons and nerves in the brain. Research studies have suggested that its functions may be out-of-control in people with Alzheimer's disease. When this happens, the neurons in the brain begin to fire quickly and uncontrollably and eventually may die. By reducing the amount of this neurotransmitter in the brain fewer cells die. This helps to preserve the thinking functions in people with Alzheimer's disease, but it does not cure the disease. The drug approved by the FDA for the treatment of Alzheimer's disease in this class of drugs is memantine (the most common brand name of this drug is Namenda). It is designed to be used in the treatment of moderate to severe Alzheimer's disease. Common side effects associated with its use include nausea, headache, constipation, and dizziness. For most people who take the drug these side effects will disappear over time and doctors can treat them.

One other drug is also approved by the FDA for the treatment of Alzheimer's disease. This drug combines both the main drug in Aricept and in Namenda. The brand name for this drug is Namzaric. Because this drug combines both FDA approved drugs for the treatment of Alzheimer's disease it can be used in the treatment of all stages of Alzheimer's disease. However, it is commonly used for moderate to severe stages. Its side effects can consist of combinations of side effects that typically happen with the use of either Aricept or Namenda. These side effects are typically treated by doctors in the same way that those side effects would be treated.

Doctors may use other medications to assist in the treatment of cognitive symptoms in people with Alzheimer's disease. For instance, some people with Alzheimer's disease may be very slow and have low energy levels. In this case, the doctor might prescribe a very mild stimulant drug. The use of medications in situations like this requires very close supervision by a doctor. It is important to make sure that the drug does not cause any problems with the person's functioning or result in any unusual side effects that could be uncomfortable or even dangerous for the person. When doctors use a drug in this way it is often referred to as "off label use." What this means is that the drug is being used for a situation that it may not specifically be designed to be used for, but its use may help the person. Doctors can use drugs in this way if they feel it is appropriate to do so. However, they are required to carefully consider the safest way and drug to use in these situations and then to monitor the person closely to make sure that there are no ill effects.

The FDA does not approve any medications for specifically addressing emotional or psychological issues in people that have Alzheimer's disease. However, there are many medications that are approved to treat emotional and psychological problems in nearly everyone. The medication used by the doctor will depend on the specific circumstances and on the needs of the person. These medications can include:

Antipsychotic drugs: These are a group of medications that are designed to address psychosis. Psychosis is a general term used to describe people that lose contact with reality. Most often these people hallucinate (they see, hear, smell, etc. things that are not there) and/or have delusions (beliefs that are not logical such as believing that everyone is out to hurt them). These drugs also may have a calming effect and can be used for people with dementia. The problem with the use of these drugs is that they may have serious side effects and doctors must monitor their use closely. Some of the antipsychotic drugs used in the treatment of emotional and behavioral issues with Alzheimer's disease include risperidone (common brand name Risperdal), haloperidol (common brand name Haldol), and quetiapine (common brand name Seroquel).

Anti-anxiety drugs: As their name suggests, anti-anxiety drugs are designed to address issues with anxiety. These drugs can also be used to help people sleep. Common anti-anxiety drugs include benzodiazepine drugs like alprazolam (common brand name Xanax), diazepam (common brand name Valium), and lorazepam (common brand name Ativan). These drugs can become addictive and may have significant side effects such as making people with Alzheimer's disease very slow and have low energy levels. Doctors who prescribe them to people with Alzheimer's disease often need to closely monitor their effects on the person.

Antidepressant drugs: This class of drugs can treat depression and issues with anxiety. There are several subclasses of drugs in this category that all have different types of side effects. Common antidepressant drugs include drugs like fluoxetine (common brand name Prozac) and sertraline (common brand name Zoloft). The antidepressant drug trazodone (common brand name Desyrel) is often prescribed to help people sleep. Other medications can be prescribed for other types of symptoms/issues.

Behavioral Interventions

People with Alzheimer's disease can also benefit from other types of treatments that do not involve the use of drugs. These are most commonly referred to as "behavioral interventions." They often attempt to replace one type of behavior with another type of behavior. For example, a person with Alzheimer's disease that is very agitated could be placed in a very quiet environment to calm them down. The use of music has been shown to be helpful to assist people with Alzheimer's disease to calm down and even to help them to function without significant assistance in some cases. A person with Alzheimer's disease in the very early stages that has mild memory problems could benefit by having a person repeat things to them to help them remember things such as how to prepare a simple meal. The helper could slowly provide verbal instructions in a step-by-step way to help the person with Alzheimer's disease prepare a simple meal. There are many types of behavioral interventions that can be useful in the treatment of Alzheimer's disease. These interventions are often used in combination with medications to assist in the treatment of issues associated with Alzheimer's disease.